Body dissatisfaction as a predictor of disordered eating behaviors in undergraduate women: an integrative review

This study aimed to investigate whether there is a relation, as well as its configuration, between the dissatisfaction with body image and the occurrence of disordered eating behaviors in undergraduate female students. For this purpose, an integrative review was Research, Society and Development, v. 9, n. 9, e661997513, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i9.7513 2 conducted in the Lilacs, Scielo, PMC and PubMed indexed databases in January and February 2019, by means of DeCS and BVL terms: feeding/ eating behavior, college/ university students, body dissatisfaction, and eating habits. The search resulted in 433 references with a final sample of 21 articles, which underwent summarization, and evidenced not only that body dissatisfaction is a potent component for the adoption of high-risk eating habits, but also that women face great social pressure regarding their weight and body shape.

433 results were found and 21 articles were selected in this review, as observed in Table 1. There is a great predominance of international journals, especially in the European continent (33.3%), with 3 journals from England, 2 from Switzerland, 1 from Germany, and 1 from Spain, while North America was in second place (28.6%) with 5 articles from the United States and 1 from Mexico. The Asian continent also had a significant participation (19.1%), with 1 publication from Bangladesh, 1 from Singapore, 1 from South Korea and 1 from India. There were 3 publications from South America (14.3%), 2 from Brazil and 1 from Chile; and there was 1 article from Oceania (4.8%), specifically from Australia.
Regarding study sites, the Asian continent surprised with 7 studies (including Turkey in Eurasia), surpassing the amount of European studies, which were 5. The American continent produced 9 studies, highlighting Brazil with 4 studies.

Research design
The objectives of the reviewed studies, in general, consisted of: body image evaluation (perception, level of satisfaction, distortion, among other variables); prevalence of body dissatisfaction; disordered eating behavior and media influence; risk of developing eating disorders and its relation to eating habits/patterns; identification of risk factors for eating disorders; relation between body image perception and eating behavior; gender differences in the relation between body dissatisfaction and risk for eating disorders; preliminary understanding of the dietary practices used to obtain the desired body weight. Table 2 presents the information about objectives, data collection instruments and sample.  Development, v. 9, n. 9, e661997513, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i9.7513 Inventory (EDI-3). Glashouwer et al. (2018) Research, Society and Development, v. 9, n. 9, e661997513, 2020 (CC BY 4. Research, Society and Development, v. 9, n. 9, e661997513, 2020 (CC BY 4 Research, Society and Development, v. 9, n. 9, e661997513, 2020 (CC BY 4.

The relationship between body and eating
All studies analyzed in this review provide evidence that corroborate the sensitive relationships between body and eating habits. Table 3 presents the main results.
Students with a high desire for thinness have higher body weight and tend to skip dinners. A positive correlation was identified between weight, body dissatisfaction and the motivation for thinness. 41.8% of the students reported not being satisfied with their weight, and obtained statistically significant scores compared to those who were satisfied in the following subscales of EDI-3: wish for thinness, bulimia, body dissatisfaction, low self-esteem, personal alienation, interpersonal alienation, interoceptive deficits, emotional dysregulation and asceticism. The review also showed that participants with high body dissatisfaction tended to have fewer main meals and to skip breakfasts and dinners. Glashouwer et al. (2018) Women with high body dissatisfaction were characterized by relatively strong and implicit "I am fat/I am not thin" beliefs, while their implicit "I want to be thinner" beliefs were similar to those of individuals with low body dissatisfaction.
The stronger the beliefs, the greater the apparent dietary restriction self-reported.
However, implicit beliefs about body image showed no higher value related to explicit beliefs of body image in predicting body dissatisfaction and diet behavior.

Llamazares et
al. (2017) Women showed a greater obsession with thinness and body dissatisfaction compared to men (13.4% vs. 4.2% and 39.4% vs. 21.9%, respectively). Bulimic behaviors were present mainly in women (21%) and predominantly in the ones under 20 years of age. In order to control weight, 2.9% of the students presented induced vomiting behavior and 2.3% showed a high use of laxatives, mainly women between 18-25 years of age; 7.7% of the students were underweight and had excessive concern with eating and body weight.
McNeill et al.
Women reported higher levels of body dissatisfaction and eating disorder than men did. The study showed that personality factors were significantly related to body dissatisfaction in both genders. In addition to the influence of body mass index (BMI), several personality traits contributed significantly to the prediction of male body dissatisfaction (such as high neuroticism and low awareness) and female dissatisfaction (such as high neuroticism). Among women, disordered food scores were significantly predicted by high neuroticism, extroversion and low awareness.
Silva et al.
In the overall sample, the prevalence of individuals with high probability of developing eating disorders was 24.4%. For Brazilian, Portuguese and Mozambican students, the prevalence was 28.7%, 23.8% and 15.7%, respectively. In the Brazilian and Portuguese samples, individuals who used medication and supplements for body alterations, as well as students classified as overweight and obese, presented a higher chance of developing eating disorders.
In the Mozambican sample, no variables changed the probability.
Regarding the predictors of disordered eating behaviors, the results revealed that body dissatisfaction prospectively predicted all disordered eating thoughts and desires (thoughts of restriction, exercise, vomiting and need for compulsive eating) and a higher probability of subsequent restriction attempts, exercises and compulsive eating.
A significant positive relationship between depression and eating disorders and a negative relationship between body image acceptance and depression were found, as well as a relationship between body image satisfaction and susceptibility to eating disorders. In addition, the regression analysis showed that depression was partially mediating the effect of body image on eating disorders.
The body dissatisfaction rate for women was 59.9% among heterosexuals, 60% among lesbians and 63.8% among bisexuals. The "unhealthy weight control" profile was higher among students of sexual minorities (gay and bisexual) compared to heterosexuals (variation: 8.9% -17.0% vs. 5.7% for heterosexual women; variation: 6.2% -25.7% vs. 2.0% for heterosexual men). This profile was associated with obesity, low body satisfaction and poor quality of life in multiple subgroups of gender/sexual orientation. Batista et al. (2015) 79.4% of women presented no body dissatisfaction; 15.3% showed mild dissatisfaction; 4.7% moderate dissatisfaction and 0.6% severe dissatisfaction.
100% of men were classified as free from dissatisfaction. Moreover, 24.1% of women and 2.4% of men were at risk for eating disorders through unhealthy eating behaviors. Regarding both genders, 48.8% were classified with high internalization of the media body ideal, and 46.0% of men and 47.1% of women showed high levels of body checking behavior.
Ko et al.
Low weight students ( 14.0% of women and 9.3% of men on PESD, 5.9% of women and 0.0% of men on DDN, and 1.3% of women and 0.0% of men on SOC, presented high risk of developing eating disorders. Regarding body perception, the concern with body shape (moderate and accentuated) was greater on the ESDP (7.4%), compared to NDD (5.2%) and SOC (1.9%) students, higher scores were found for women.
Ohara et al.
Among women, the ideal body shape was smaller than the perception they had of their actual body shape. Among participants with normal weight, the DEBQ scores for restrained, emotional and external eating were higher in women than in men. BMI was positively associated with eating in both sexes. For women, emotional eating was negatively associated with the discrepancy on the current/ideal BMI and body shape.
Vartanian et al. (2014) Early adverse experiences were negatively associated with interpersonal and intrapersonal resources. Intrapersonal resources were negatively associated with body dissatisfaction, while interpersonal resources were positively associated with body dissatisfaction. Finally, body dissatisfaction was associated with a series of disordered eating behaviors (compulsion, purging and restriction) and strenuous exercises.
Yean et al.
Women endorsed significantly more body dissatisfaction, motivation for thinness, internalization, and disordered eating symptoms than men, who, on the other hand, endorsed more impulse for muscularity. The results also indicated that body dissatisfaction and low self-esteem partially mediated the relationship between internalization and eating disorder symptoms. Compared to heterosexual women, lesbians reported a greater impulse to muscularity, low self-esteem, and lower internalization, but they did not differ significantly in body dissatisfaction, motivation for thinness, and disordered eating.
Memon et al.
Gender differences on the two questionnaires' scores were statistically significant towards women, who scored higher than men did on all scales, except for the B scale of EDI-3-RF (bulimic behaviors), in which men scored slightly higher.
According to the diagnostic criteria proposed in EDI-3-RF, 11.9% of men and 29.9% of women were included in the "high risk" group.
26% of students reported smoking, 8% reported taking laxatives and 4% reported taking dietary pills. 50% of students affirmed to be engaged in regular physical activity and 19% claimed to use multivitamin supplements. The research found that 64% of the students were not worried about their body image, 19% were slightly worried, 12% were moderately worried and 5% were extremely worried (89% were women). The levels of body dissatisfaction of students who reported using laxatives and dietary pills were much higher than those who reported smoking, exercising regularly or taking multivitamins.
Costa et al.
A prevalence of abnormal eating attitudes (8.3%) was found among women students, as well as a prevalence of body dissatisfaction (20.0%). The group of students dissatisfied with their body images showed a significantly higher prevalence of abnormal eating attitudes (34.2%) when compared to the group of students satisfied with their body images (2.3%).
Bosi et al.
The difference between the reported and the desired weight was, on average, of 2.2 kg, indicating general dissatisfaction in relation to their reported weight.
26.29% of students presented abnormal eating behavior. The students who presented moderate/severe body dissatisfaction (66.7%) presented risky eating behaviors twice more frequent than those with mild/normal body dissatisfaction did.
Considering that excessive concern with body and dissatisfaction with body image are highly associated with risk behaviors for eating disorders, research conducted in this area investigate the individuals' perceptions about body shape and size, as well as the frequent eating behaviors, with a greater focus on women (Bosi et al., 2009;Glashouwer et al., 2018;Nergiz-Unal et al., 2014).
Gender is recognized as a risk factor for eating disorders. Women experience higher social pressure on weight and body shape compared to men, which can result in anxiety, depression, low self-esteem, low level of self-confidence, and dissatisfaction with body image. For them, disordered eating behaviors have become so common in Western society that restrictive diets, as well as compensatory and purgative practices, are commonly considered "normal" behaviors. This normalization results in the intensification of behaviors harmful to women's health (Iorga et al., 2018;Batista et al., 2015;Macneill et al., 2017;Talwar, 2012;Yahia et al., 2011).
In a systematic review, Lindvall, Dahlgren and Wisting (2016) assessed the prevalence of eating disorders and found overall rates that ranged from 0.5% to 5.3% for women and